Neoplasm of Large Intestine

Prof. Feroze Prof. Feroze QuaderQuaderDept. of SurgeryBegum Khaleda Zia Medical College

Polyp:

A grape-like protrusion of tissue into the bowel lumen.

a)Sessile: flat on the mucosal surface

a)Pedunculated: Has a stalk b)Epithelial or submucosal c)Non-Neoplastic Polypsd)Neoplastic Polyps

Non-neoplastic Polyp

a) Hyperplastic polyps

b) Juvenile Polyps c) Peutz-Jegher

Polyps (Syndrome)

Peutz-Jegher’s syndrome

Neoplastic Polyp (adenoma)

a) Tubular adenomab) Villous Adenomac) Tubulovillous

adenoma

Tubular Adenoma Villous

It is a general neoplastic disorder of the intestine.

Affected area: Mainly large bowel.

Other : Stomach, duodenum & small intestine

The most important thing about adenomatous polyposis coli is that colorectal cancer develops before age 40 in nearly all untreated patients.

  It is inherited as a Mendelian dominant . The

gene responsible (APC gene) has now been identified on the short arm of chromosome 5.

  Males & females are equally affected.

Symptomatic patients:

Loose stoolLower abdominal painWeight lossDiarrhoeaPassage of blood &Mucus.

Asymptomatic patients:

Usually are diagnosed during screening or incidentally.

Clinical features

Clinical features…

Polyps are usually visible on sigmoidoscopy by the age of 15 years and will almost always be visible by the age of 30.

Carcinoma of the large bowel occurs 10-20 years after the onsent of the polyposis.

Some extra-cortical manifestations

Benign

Endocrine adenomeOsteomaEpidermoid cystHypertrophic retinal pigmentationMedulloblastoma

Malignant

Duodenal carcinomaDesmoid tumorBile duct, pancreatic carcinoma Carcinoma stomach

Treatment

Restorative proctocolectomy with an ileoanal anastomosis:(Now-a- days more frequently used)

Indicated specially in cases 

• With serious rectal involvement with polyps• Who are likely to be poor at attending for follow up• With an established cancer of the rectum or sigmoid.

Treatment

Colectomy with ileorectal anastomosis :

was practiced in past as usual operation because it avoids an ileostomy

in a young patient.

Treatment

Restorative proctocolectomy with an ileoanal anastomosis:(Now-a- days more frequently used)

Indicated specially in cases 

• With serious rectal involvement with polyps• Who are likely to be poor at attending for follow up• With an established cancer of the rectum or sigmoid.

DietLow fibre containing dietSmoked fishHigh content of refined carbohydrate in Diet red meat Less intake of micronutrients specially Selenium

deficiency.

Predisposing Factors

Pathology

Microscopically

The neoplasm is a columnar cell Carcinoma originating in the colonic epithelium. 

Macroscopically

The tumor may take one of four forms . Type 4 is the least malignant form.

Pathology

Types of growth

Spreading

• Local spreading• Lymphatic apreading• Hematogenous spreading

Staging

Dukes’ classification A Confined to bowel wall.

B Through the bowel wall but not involving the free

Peritoneal serosal surface .

C Lymph nodes involved. D advanced local disease or metastasis to liver.

CARCINOMA COLONClinical Feature

Carcinoma of the left side of the colon:

PainAlteration of bowel habitPalpable lumpDistension

CARCINOMA COLONClinical Feature…

Carcinoma of the sigmoid:

PainTenesmusBladder symptoms

CARCINOMA COLONClinical Feature

Carcinoma of the transverse colon:

Palpable lumpAnaemiaLassitude

CARCINOMA COLONClinical Feature

Carcinoma of the caecum and ascending colon:

AnemiaLump in right iliac fossaAcute appendicitisIntermittent obstruction

CARCINOMA COLONClinical Feature

May present with features of metastasis

• Palpable Liver• Jaundice• Ascites

CARCINOMA COLONInvestigations

Diagnostic:

EndoscopySigmoidescopyColonscopy

With tissue biopsy

Investigations

Radiology

Double contrast barium enemaShows Irregular filling defect

Ultra-sonographyLiver metastasis

CT ScanLocal invasion specially in Pelvis

Treatment

Preoperative preparation:

General : Correction of anaemia by blood Correction of nutritional imbalance Correction of electrolyte imbalance Resuscitation

if there is - intestinal Obstruction, perforation

Treatment

Special preparation:

Bowel preparation by Dietary restriction to fluids for 2 days before

operation. Laxative Enema prophylatic antibiotic

Treatment

Operation:

Laparotomy is done The tumor is assessed for resectibility by

checking involvement in Liver Peritoneum Local lymph nodes Tumor itself for Mobility

Treatment…

In case of operable cases: Operations are done to remove the primary

tumor and the draining lymph nodes. Removal of the portion of colon surrounding the

tumor area depends on site of original of tumor.

Carcinoma of the caecum/ascending colon. Right hemicolectomy

Carcinoma of the hepatic flexure: resection will be extended correspondingly

Treatment…

In case of operable cases: Carcinoma of transverse colon: ▪ Excision of transverse colon & the two flexures

together with the transverse mesocolon and the two flexures together with the transverse mesocolon and the greater omentum followed by end – to – end anastomosis.

▪ Alternative is an extended right hemicolectomy. Carcinoma of the splenic flexure or descending

colon:▪ Resection from right colon to descending colon.

Sometimes removal of colon upto the ileum, with an ileorectal anastomosis.

Treatment

In case of inoperable cases:

Palliative procedure is done:

Transverse colostomy if growth in upper part left colon

Left Illiac fossa colostomy for Pelvic colonic growth

By-pass Illio-colic anastomosis for ascending colon-growth